Effective measurement of treatment outcomes has long been a critical
issue in the development of the Nation's alcohol and other drug (AOD)
abuse treatment system. Studies of methadone maintenance treatment
programs indicate that variables such as adequacy of methadone dosing
levels, staff turnover rates, and differences among counselors correlate
significantly with patient performance. These factors are, nonetheless,
rarely taken into account by standard measures of treatment
effectiveness (Gerstein and Harwood, 1990).
This chapter provides general information on quality improvement and
outcomes measurement. A more detailed discussion of these issues as
they relate to AOD abuse treatment is found in another Treatment
Improvement Protocol (TIP) in this series, Developing State Outcomes
Monitoring Systems for Alcohol and Other Drug Abuse Treatment (TIP 14; Center for Substance Abuse Treatment, 1995).
It is intended as an aid in developing, implementing, and managing
outcome monitoring systems.
The move toward health care reform and the growing concern for
financial accountability have made service providers increasingly aware
of the need to ensure quality care. One potentially useful document,
prepared by an organization with standing in the addictions field, is a
10-step quality assurance checklist issued by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) (see Exhibit 5-1).
The specific indicators of quality shown in Exhibit 5-1 are of particular importance.
Staff can perform chart reviews to verify the quality improvement
indicators. Routine weekly reviews of charts of 25 percent of the
patients seen, with followup of any problems discussed in weekly case
conferences, is a standard recommended by JCAHO (Joint
Commission on Accreditation of Healthcare Organizations, 1993).
Treatment staff should complete and document each of the following steps
in the patient's record. If a step has not been performed, a reason for
the omission should be included.
Admission procedures
Document the level of withdrawal; take previous medical history
and drug use history; conduct physical examination; address legal
issues; obtain patient consent for treatment
Develop an individualized treatment plan
Develop and initiate a plan for discharge and aftercare
Conduct formal assessment.
Primary services
Evaluate the patient's physical and psychological status (must
include a medical history and physical examination within 24 hours, if
these were not performed at admission)
Develop a plan documenting the anticipated course of medical and
social management
Develop a plan for continuing care (involving the patient's family
or significant others in treatment, when possible)
Perform routine drug screens
Flag files to indicate (1) previously treated patients and (2)
patients with special medical problems, such as insulin-dependent
diabetes, a history of seizures, drug sensitivities, or psychiatric
comorbidity
Consult previous admission data and treatment plans, if
available.
Financial information
Obtain at admission; seek reauthorizations as required
Provide assistance in obtaining entitlements such as Medicaid.
Discharge and aftercare
Identify patient's continuing needs for medical
care, housing, legal assistance, food stamps, child care, or other
services
Address legal problems (e.g., for court-referred patients)
Comply with legal mandates and reporting requirements.
The programs' internal management information system should include
clinical reports, incident reports, followup reports from referral
resources, insurance and accreditation reports, and public health and
other Government inspection reports. In addition, any other
quality-improvement reports that have been generated to analyze trend
data drawn from patient charts should be included. Every treatment
program should have such a system in place to capture and compile these
data so that program administrators can take a step back from reviewing
the charts of individual patients to look at the entire patient
population. The following indicators should be documented:
Patient demographic data
Primary and secondary drugs used at admission
Sources of referral into the program, plus any changes in referral
patterns
Accuracy and timeliness of intake assessments (e.g., significant
problems not identified at initial assessment, changes in the treatment
plan, indications that clinical care was not appropriately
individualized)
Admissions processed within designated time frames
Number of people interviewed who were not admitted (where they went
and why)
Number of individuals on the waiting list for admission and the
average length of time on the waiting list (with note made of any
changes cyclically and over time)
Ratio of planned discharges versus the number of patients who left
against advice (the case manager's unscheduled discharge report is a key
document for this indicator)
Staff data on training completed, turnover rates, internal promotion
and transfer rates, staff complement (overall and by specialized unit),
staff credentials, and training relative to job responsibilities and
program licensure requirements
Safety, security, sanitation, and insurance inspection reports
Financial performance (e.g., evidence that reimbursements are billed
accurately and promptly, all eligible funds are applied for, appropriate
financial procedures are in place, financial records are in order and
independently audited on a regular schedule).
The National Institute on Drug Abuse has published a technology
transfer package to help program administrators and staff who have no
previous experience or formal training in evaluation to plan and conduct
evaluations of their programs. The package is titled How Good Is
Your Drug Abuse Treatment Program? and includes an overview and case
study manual, an evaluation guide, a resource manual, and looseleaf
worksheets and agendas. The procedures and steps discussed in the guide
conform to the standards of JCAHO. It is available free of charge from
the National Clearinghouse for Alcohol and Drug Information at (800)
729-6686 or (301) 468-2600; TDD (for hearing impaired) at (800)
487-4889.
A recent contribution to the literature on addiction treatment is the
public policy statement on recommendations for design of treatment
efficacy research with emphasis on outcome measures (American Society of Addiction Medicine, 1994a).
These recommendations, developed from a consensus process involving more
than 70 experts in the addictions field, begin by identifying the nine
"essential elements" of studies that assess quality of treatment. They
include
The starting number of patients
Initial patient characterization
Comparison with two or more groups
Description of the treatment program
Continuing-care compliance, frequency, and duration
Discharge category
Number of patients followed up on
Followup time
Cost.
Within this framework, the American Society of Addiction Medicine
recommends measurement of eight variables, as shown in Exhibit 5-2, but cautions that confirmation of
patient self-reports of AOD use or nonuse is desirable, through either
biochemical analysis or corroborative reports.
An appropriate system for measuring outcomes, no matter how simple or
complex, must also take into account the goals of detoxification. Three
desirable goals are to safely manage withdrawal; to engage the patient
in treatment; and to provide withdrawal that is humane and respects the
patient's dignity. The following list presents detoxification-specific
outcomes indicators that are appropriate for these goals and may be used
in conjunction with other measures.
Number of times that patient records were released pursuant to a
properly signed consent or court order and the number of incidents in
which information was inadvertently released without consent or a
compelling court order
Number of times that patients were deprived of rights that are
generally accorded to program participants.
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